|
0 9
<br /> Emergency Barnett Medical Services Inc CALIFORNIA RMW-CLASS6.2 UN3291
<br /> Phone Number P.O. Box 4436, Hayward CA 94540
<br /> (925)321-5938 REGULATED BIOMEDICAL WASTE TRACKING FORM
<br /> 1.Generator's I No.. IA.Generator's EPA No.: 1B.Generator's DEA NO.: 2.Tracking Form Doc.No.;
<br /> Em
<br /> Ph
<br /> (92
<br /> Phone
<br /> g
<br /> 32
<br /> IN
<br /> Emergency
<br /> Number
<br /> y
<br /> mb
<br /> 9
<br /> e
<br /> 5 "1 5 39 REGULATED
<br /> 1 IA_ Date: 2 Tracking-62763 2019
<br /> 10-04-2019 62763-10-04-2019-291210-BB
<br /> 3_Generator's s Name and Site Ad 7��; Nameand Billing Address:
<br /> Satellite Dialysis-Stockton Satellite Healthcare
<br /> 590 E Harding Way 300 Santana Row#300
<br /> �c
<br /> StDckton,CA 95204 San jose,CA 95128
<br /> Generator's
<br /> P 0 e um rf'j,
<br /> 4.Generator's Phone Number(s)with Area Cod-e- 4A;Generator's Billing Phone Number with Area Code:
<br /> (209)774-5800 (650)404-3600
<br /> 6.Transporter Company Name: 7.Transporter 1.D.Numbers:
<br /> Barnett Medical Services Inc CALIFORNIA LISDOT#
<br /> P.O.Box 4436,Hayward CA 94540 DTSC#6183
<br /> (800)748-1803
<br /> 8.Transfer Facility Name/Address:- 9.Treatment Facility N 10.Alternate Treatment Facility—
<br /> Barnett Medical Services-Modesto Barnett Medical services-Modesto Daniels Sharpsmart
<br />
<br />
<br /> (559)834-6252 Permit#:TS/OST-55
<br /> 11, Description of Waste
<br /> 12.Container Type(Quantity) 13.Weight(Lbs)
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2, PG It QR:d5f25f0,Destroyed 10/07/20140 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2, PG 11 QR:d605a53,Destroyed 10/07/2 X9 gal Bio Disposal(1)
<br /> 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2, PG 11 QR:d60cf0d,Destroyed 10/07/2(=gal Bio Disposal(1) 37.00
<br /> UN3-291, Regulated Medical Waste,N.O.S,6.2,PG 11 QR:d6145c0,Destroyed 10/07/2049 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 OR:d61ba59,Destroyed 10/07/2 XG gal Bio Disposal(1) 37.00
<br /> LIN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:d601fdc.Destroyed 10/07/2(18 gal Bio Disposal(1) 37.00E
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:d610a0f,Destroyed 10/07/2(49 gal Bio Disposal(1) 00
<br /> 37.0
<br /> 0
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:d61800a,Destroyed 10/07/2;)49 gal Bio Disposal(1) 377.00
<br /> 14)Special Handling Instructions and Additional Information:
<br /> 15)Generator's Certification:
<br /> I hereby declare that the contents of this consignment are fully and accurately described above,and are classified,packaged,marked and
<br /> labeled I placarded,and are in all respects in proper condition for transport according to applicable International and national
<br /> governmental regulations.
<br /> X X Date 10.04-2019
<br /> Sign Print N e—
<br /> 'X' Ica[Services Inc CALIFORNIA V/
<br /> X X Ma!111 Montez Date 10-04-2019
<br /> HaulCrs Signat re rint Name
<br /> 17)Discrepancy Indication Space: ---
<br /> Initia(s:
<br /> Date:
<br /> 18)Receipt of Materials Covered by this Manifest: 19)Certificate of Destruction: The signature below certifies that the waste documented
<br /> an this'tracking*wrlrel Pd in accordance with applicable legal requirements on the date
<br /> indicated
<br /> 10-04-2019
<br /> Date Signature Date
<br /> X BRETT ESPICHA X BRETT ESPICHA II)ESTROTED,
<br /> 1_Print Name .Print Name 1e—'3L0LCL7LZ0jj.,— I
<br />
|